Albuterol by EMT-Bs; Pediatric Prehospital Training Comparison; Child Safety Seats

Albuterol for Bronchospasm by EMT-Bs

Markenson D, Foltin G, Tunik M et al. Albuterol sulfate administration by EMT-Basics: Results of a demonstration project. Preh Emer Care 8(1):34–40, Jan.–Mar. 2004.

Abstract: Objectives—1) To evaluate the ability to train Emergency Medical Technicians-Basic (EMT-Bs) to accurately identify bronchospasm and, based on a treatment protocol, administer albuterol sulfate via nebulization as a standing order; 2) To measure the improvement in patient condition after treatment. Methods—Following approval by the Commissioner of Health and Institutional Review Board, EMS agencies were enrolled to participate in the study, and EMT-Bs were trained using a four-hour curriculum. For each patient, a prehospital data collection form was completed, including identifying data for the EMT-B, patient assessment and history information. Also, pre- and post-treatment assessments and hospital data collection forms were completed, including the emergency department physician’s diagnosis, assessment of bronchospasm, number of albuterol treatments received in the emergency department, and final disposition of the patient.

Results—During a one-year study period, EMT-Bs treated 190 patients as part of the project. Across all values, patients showed a clinical improvement as a result of the therapy. Concurrence in the assessment of bronchospasm by the EMT-B with an emergency department physician was found in 87.4% of the cases. When including allergic reaction, anaphylaxis, bronchiolitis and chronic obstructive pulmonary disease in the diagnosis list of bronchospasm, the accuracy rate increased to more than 94%.

Conclusions—This study indicated EMT-Bs were highly successful in their evaluation of bronchospasm. Based on this level of accuracy, the authors suggest that it is safe for emergency medical service systems and medical directors to develop protocols that allow EMT-Bs to administer albuterol via nebulizer for bronchospasm based on their assessment.

Comment: This is another study demonstrating that EMT-Bs can, with a limited amount of additional training, accurately identify and safely treat patients with additional medications and procedures. A study from rural California presented similar results when EMTs were trained to insert a Combitube and administer naloxone, glucagon, nitroglycerine, albuterol, activated charcoal and epinephrine. The training to properly assess and treat using these “advanced” skills should be further studied. EMS systems that have prolonged paramedic response times should look at supplementing their EMT-B scope of practice with one or more of these items.

Pediatric Prehospital Training Comparison

Sanddal ND, Sanddal TL, Pullum JD et al. A randomized, prospective, multisite comparison of pediatric prehospital training methods. Ped Emer Care 20(2):94–100, Feb. 2004.

Abstract summary: Objective—Results of prehospital pediatric continuing education using train-the-trainer and CD-ROM training methods were compared to each other and to a control group. The null hypothesis was that no differences would be found in pre-training and post-training measurements of knowledge and performance by either training method.

Methods—This was a prospective trial involving 12 sites. Random selections were made from ambulance service lists provided by three state emergency medical services (EMS) agencies. Pre-intervention and post-intervention (12-month) measurements included a written examination and two performance scenarios videotaped for independent panel evaluation. Training was either an interactive CD-ROM or standard classroom instruction using a train-the-trainer model. Mean differences in written, performance and combined scores were analyzed.

Results—Differences were noted in the combined and performance scores for the CD-ROM intervention group. No differences were noted in written measurements between or among the groups. Conclusion—In this small sample, interactive CD-ROM training shows promise for improving performance. The research design, with additional guards against sample size attrition, may provide a model for multisite EMS education research.

Comment: “Train-the-trainer” teaching has been part of EMS since at least the start of the EMT curriculum. However, many factors limit the effectiveness of this technique. Newly trained individuals often do not yet have sufficient subject matter expertise or educational training to teach. Quality of the subsequent training can be widely variable. More recent educational studies have indicated there may be a better way. Videotapes, interactive CDs, Web-based and other “distributed learning” methods have been shown in a number of EMS-related studies—such as for CPR, airway management and AED use—to be effective. In this study, the CD training seemed to be superior to the train-the-trainer approach. If available, consistent and customizable to the schedule and knowledge of the student, these alternative training methods have great promise.

Appropriate Child Safety Seats

Edgerton EA, Orzechowski KM, Eichelberger MR. Not all child safety seats are created equal: The potential dangers of shield booster seats. Pediatrics 113(3):e153–8, Mar. 2004.

Abstract: Children are safest when traveling in a child safety seat appropriate for their age and size. Previous research indicates that children are often transitioned to shield booster seats (SBSs) before reaching the 40-lb. weight limit for their forward-facing child safety seat (FFCSS). These children could have otherwise been restrained in an FFCSS, as is currently recommended by the American Academy of Pediatrics and the National Highway Traffic Safety Administration (NHTSA). The objective of this study was to compare the injury patterns among children who were restrained in SBSs and FFCSSs. Children in FFCSSs were chosen as a comparison group because SBSs are predominantly used to restrain children between 30–40 lbs. who could have been restrained in an FFCSS, and SBSs are no longer certified for use in children who are over 40 lbs.

Methods—This was a cohort study involving restrained crash victims who were admitted to a Level 1 pediatric trauma center between 1991–2003. Patients were older than one year and weighed between 20–40 lbs.; data from 30 children restrained in FFCSSs were compared with data from 16 in SBSs. Injury severity score, abbreviated injury scale, Glasgow coma score, intensive care admission, length of stay and acute care charges served as outcomes of interest.

Results—Crash and vehicle occupant characteristics were similar for the two groups, with no statistically significant differences among crash types, passenger compartment intrusion, driver restraint use, fatalities, etc. However, children in SBSs had nearly eight times the odds of serious injury compared with the other group; hospital stays were longer (six days compared with three); and acute care charges were higher (an average of $30,000 versus $9,000). Furthermore, in all the other categories—abbreviated injury scale, Glascow coma score and intensive care admission, as well as the number of head and abdominal/pelvic injuries—the methodology’s odds ratio (OR) and confidence interval (CI) measurements were significantly higher for the SBS group.

Conclusion—This study provides information about the increased risk of injury associated with shield boosters when compared with FFCSSs.

Comment: Child safety seats unquestionably prevent death and injury. Most parents understand the importance (and legal requirement) of safety seats for younger children. However, additional education is needed for parents of children nearing 40 lbs., when many are transitioning the children into booster seats. This study reinforces the current NHTSA recommendation that children between 20–40 lbs. should be restrained in forward-facing child safety seats, rather than shield boosters, which are not a suitable transition to the belt-positioning boosters required for children >40 lbs. EMS providers can help in this effort by both promoting child restraints and educating parents on the most appropriate type.